Effect of neuromonitor-guided titrated care on brain tissue hypoxia after opioid overdose cardiac arrest.

Abstract

INTRODUCTION:

Brain tissue hypoxia may contribute to preventable secondary brain injury after cardiac arrest. We developed a porcine model of opioid overdose cardiac arrest and post-arrest care including invasive, multimodal neurological monitoring of regional brain physiology. We hypothesized brain tissue hypoxia is common with usual post-arrest care and can be prevented by modifying mean arterial pressure (MAP) and arterial oxygen concentration (PaO2).

METHODS:

We induced opioid overdose and cardiac arrest in sixteen swine, attempted resuscitation after 9 min of apnea, and randomized resuscitated animals to three alternating 6-h blocks of standard or titrated care. We invasively monitored physiological parameters including brain tissue oxygen (PbtO2). During standard care blocks, we maintained MAP > 65 mmHg and oxygen saturation 94-98%. During titrated care, we targeted PbtO2 > 20 mmHg.

RESULTS:

Overall, 10 animals (63%) achieved ROSC after a median of 12.4 min (range 10.8-21.5 min). PbtO2 was higher during titrated care than standard care blocks (unadjusted β = 0.60, 95% confidence interval (CI) 0.42-0.78, P < 0.001). In an adjusted model controlling for MAP, vasopressors, sedation, and block sequence, PbtO2 remained higher during titrated care (adjusted β = 0.75, 95%CI 0.43-1.06, P < 0.001). At three predetermined thresholds, brain tissue hypoxia was significantly less common during titrated care blocks (44 vs 2% of the block duration spent below 20 mmHg, P < 0.001; 21 vs 0% below 15 mmHg, P < 0.001; and, 7 vs 0% below 10 mmHg, P = .01).

CONCLUSIONS:

In this model of opioid overdose cardiac arrest, brain tissue hypoxia is common and treatable. Further work will elucidate best strategies and impact of titrated care on functional outcomes.

• Authors: Jonathan Elmer, Katharyn L Flickinger, Maighdlin W Anderson, Allison C Koller, Matthew L Sundermann, Cameron Dezfulian, David O Okonkwo, Lori A Shutter, David D Salcido, Clifton W Callaway, James J Menegazzi
• Journal: Resuscitation (Resuscitation) Vol. 129 Pg. 121-126 (08 2018) ISSN: 1873-1570 [Electronic] Ireland
• PMID: 29679696 (Publication Type: Journal Article, Research Support, N.I.H., Extramural)
• Copyright: Copyright © 2018 Elsevier B.V. All rights reserved.

Chemical References

• Analgesics, Opioid

Topics

• Animals
• Female
• Analgesics, Opioid (toxicity)
• Brain Ischemia (etiology, physiopathology, therapy)
• Cardiopulmonary Resuscitation (methods)
• Cerebrovascular Circulation (physiology)
• Cross-Over Studies
• Disease Models, Animal
• Drug Overdose (complications, physiopathology)
• Heart Arrest (chemically induced, physiopathology, therapy)
• Monitoring, Physiologic (methods)
• Prospective Studies
• Random Allocation
• Swine